Integrated Delivery Network Optimization

The Situation

Is your healthcare system developing integrated delivery networks in order to provide comprehensive and integrated patient care across the spectrum? Are you frustrated with the lack of visibility to network utilization patterns after a physician group is acquired? To ensure that your hospital derives maximum value from its investment in physicians, you must first measure and understand their patterns of utilization. However, your operational, clinical and financial systems most likely can’t talk to each other, let alone, with the practice management systems used by your physician practices. Without the ability to monitor resource utilization and patient referral business throughout the healthcare system, both within acute care and ambulatory settings, you may never identify or capture missing revenue caused by referral ‘leakage’ from your network.

A sample application shows the referral volume trend for a specific physician over time, making it easy to see that referral volumes are steadily decreasing.

What Is Needed Now?

Physicians must be satisfied with the range and quality of the services and feel confident when referring their patients to receive care within the system. Hospital executives and service line managers must ensure that services are conducive to quality care and physician satisfaction. If healthcare executives want to monitor whether the network continues to serve physicians and their patients in the best possible manner, they need timely visibility to physician utilization patterns and service line volumes as a key indicator. And executives need to identify where referrals are leaking from the system before they can understand and resolve resource utilization issues and eventually optimize network utilization.

• healthcare systems need a decision support system that tracks physician practice patterns and the resulting utilization volumes, even when there is no common identifier for physicians or patients in place.
• Hospital executives need the ability to measure and continually monitor how many referrals are likely “leaking” out of the system (from which doctors and from which service lines).
• Decision makers need to understand where referral traffic is coming from by service line, and where it is absent, in order to identify and address service line problems and opportunities.

The WhiteCloud Solution

WhiteCloud Integrated Delivery Network Optimization solutions provide an integrated decision support system that can track physician practice patterns and the resulting downstream referral activity to other services within a healthcare system. Designed to pull volume and charge information from physician practice management systems and core hospital systems, this solution integrates the data and builds a model that describes and measures the referrals coming from physicians and the referrals that appear to be missing. Using a set of dynamic and configurable business rules, our solution identifies where referral traffic is originating by physician and service line, and where it is absent. This helps hospital executives and other key decision makers identify and address service line problems and opportunities. While a master patient identifier (MPI) across these systems makes the processing easier, we have implemented this solution in healthcare systems without a MPI in place.

The Result: Improved Quality and Healthier Financial Outcomes

The improvements that result from this level of visibility have a major impact on quality, patient satisfaction, and the financial viability of an integrated delivery network. It is typical for an integrated system to lose money on each employed physician when accounting only for their direct professional fees (typically between $70K and $200K per physician per year, depending on specialty and work volumes). On the other hand, the referral volumes from a physician often result in $700K to nearly $2M in annual reimbursements (depending on specialty). If referral volumes are not in line with expectations, millions of dollars of potential revenue disappear from the system; and service line volumes will be lower than anticipated -resulting in unforeseen budget variances and greater overhead costs. It is not uncommon for 10%, 15%, or more of the referrals to unnecessarily leak out of a system that is unmonitored, in whole or in part. The ability to see which service lines have the most opportunity to gain referral business will allow specific and targeted service line growth and improvement strategies to ensure optimized network utilization and maximize physician and patient satisfaction with services.

WhiteCloud solutions are designed to provide cross-organizational visibility to timely and relevant information needed to ensure direct referrals from physicians and downstream business is driving operational performance and sustaining patient care volumes.